Arrest

[VentMedic]

In-line neb was up to recently our only option, we have since changed that to an MDI administered through a port on the circuit. I don't know how much would actually be delivered to the target tissues, I have no way of measuring that. As I believe someone mentioned earlier in the thread, Heliox would assist in delivering medication to the more distal airways, however pre-hospitally, the world I live in this in not an option. My plan would be to deliver this patient in better shape than I found him to a facility equipped to manage the patient better than I.

Do you feel an in-line nebulizer would do more harm than good in a very tight asthma pt? I know anecdotally that in-line nebulized albuterol has improved compliance in similar patients in my experience in the past, although other medications were also in use.

We now us MDIs on our vent patients as there is a concern with the extra flow. Also, when running a low rate, you can time the delivery with the ventilation where otherwise the nebulized med might just be lost in the circuit. There are numerous studies now on the particle depostition of both delivery methods at this has been extensively researched over the past 30+ years and now re-researched with the HFA MDIs.

I have used a self inflating BVM to bag in a nebulized med but there I do have control over the timing and the BVM is not a continuous flow.

Heliox would be the best choice initially in the ED and/or ICU to deliver meds and attempt ventilation. But I believe I did mention the drawbacks to its use on a truck even for CCT/IFT.

 

[mycrofft]

As a "lower being", I see a real mix of art and science here.

Looking at the "global" impacts of a tx or Rx and how it fits into a treatment regimen or protocol really drills home the need for a true education and constant ongoing education when you get past a certain point of treatment, as well as insightful examination of the pt weighed against "the need for speed" and on scene sense of urgency.

Maybe I'm shaking my rattle here, but is transtracheal still a potential route for Rx admin?

Also a sidetrack: inhaled meds in my humble experience work with an interesting lack of effect when sprayed onto mucus or phlegm-lined airways. Oh, and just as some of us "can't jump", some COPD pt's can't time their MDI sequence and need coaching or outright admin by others.

 

[VentMedic]

Oh, and just as some of us "can't jump", some COPD pt's can't time their MDI sequence and need coaching or outright admin by others.

Which is why spacers or holding chambers have been used for over 25 years on both ventilator and non-ventilated patients. As well, some BVMs have a port to enhance delivery or a small inline adapter can be ordered for use with the BVM.

The education part comes in keeping current with the new medications, new formulations (HFA vs CFC) and delivery devices. So "rig" equipment without actually knowing if it is acheiving what it is supposed to do but it "looks good".

as well as insightful examination of the pt weighed against "the need for speed" and on scene sense of urgency.

Does that mean if the neb is ran at 10 liters instead of 6 the "need for speed" will be taken care of?

 

[mycrofft]

Why sure..let's see....

10 lpm is 2/3 more than 6, so you could drive 2/3 slower to the hospital. That was easier than IV rate doseage conversions!

I'm aware of spacers, from the "Transformers" folding monstrosities to 50 cents worth of blue tubing. My rule of thumb gauge of efficiency getting on board is how much medicine is obviously left in the spacer afer the pt does it. (My rule of thumb gauge of efficacy is if the symptoms subside quickly). Some guys are all "I've been an asthmatic for twenty five years" and hit the MDI momentarily (subtherapeutic dose) after they finished inhaling (shot into their oropharynx and stayed there. just no sense of rythm, I take the time to teach em (without actually overdosing them or myself, of course).
I can imagine the tortuous contraptions some folks try with nebs, tubing and double male adapters. Like my erstwhile coworker who reversed the tubing nipple and the intake filter fitting on the old Pulmoaid so when I set it up and turned it on it was pumping away extra hard and nothing was working..until I accidentally tipped the nebulizer handpiece while leaning over to look at the compressor.."sluuuurp".

I remembered the transtracheal deal because the one time I saw it tried during a code the young doc apparently lanced the cuff on the trache tube.

 

[Smash]

Do you understand what shifts IV albuterol can cause which is why it has been reconsidered in many situations in the countries that have been using it? Especially in a hemodynamically unstable post arrest patient whose BP can be easily influenced?

Now if either of you find any of those MEDICAL questions offensive, I will have to say this forum has lost hope of ever carrying out a MEDICAL discussion in fear that someone will get offended if they have to think a little about the questions that have been raised about certain treatments.

Yes I do. I also understand the need for BP Support, the vagaries of CBF, CPP, ICP post arrest and how MAP can influence these. I understand the dangers of reperfusion injuries and the need to hemodilute to mitigate the effects of the products releleased.

Although of course post arrest patient's BP may not in fact be so easily influenced particularly given the possibly high prevalence of post-arrest adrenal insufficiency. However in this instance the patient was, and remained, hypertensive. Given that the patient still had significant bronchospasm I had limited options in managing this without causing still further undesireable increases in BP.

See, this is how you have a clinical discussion. It doesn't require personal abuse, baseless allegations, overweening arrogance and a hectoring tone to have such a discussion. You may find if you avoid these things people will be much happier to engage in discourse.

 

[VentMedic]

See, this is how you have a clinical discussion. It doesn't require personal abuse, baseless allegations, overweening arrogance and a hectoring tone to have such a discussion. You may find if you avoid these things people will be much happier to engage in discourse.

The only abuse was perceived by you and your own insecurity to answer a couple of very "basic" questions.

 

[Smash]

The only abuse was perceived by you and your own insecurity to answer a couple of very "basic" questions.

Goodness gracious me, you really can't help yourself can you? Is there anything else you care to make up as you go along?

I'm assuming you don't actually have any kind of mental disability that would render you unable to understand posts or to respond to them appropriately, which leaves me at a loss as to why you keep making uncalled for, unproductive, childish and frankly ridiculous personal attacks that have no basis in the discussion at hand.

 

[zmedic]

Going back a few pages someone noted that it isn't asthma since there was no wheezing. It's good to have a broad differential, but keep in mind that you need air movement to have wheezing, if the patient isn't moving much you won't hear much. That's why patient's often have increased wheezing in response to albuterol, because you are now getting better air flow through those lower airways. Remember, if the wheeze gets better but the patient looks worse, worry.

Also I didn't see anyone suggesting magnesium. I know there isn't a lot of data to support it but in a crashing asthmatic who isn't responding to treatment it's worth a thought.

 

[Smash]

The silent chest thing is something that catches a lot of people out, you are dead right. Where I work we don't see as many sick asthmatic patients as we used to, as they are better managed by their primary care physicians with better medications and escalation strategies.

I think mag sulphate was mentioned by boingo. We don't carry it at the moment, hence not being used in the initial management of this patient. I was curious that it wasn't mentioned more often, it was all the rage not so long ago.